- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.75 / $140.75 / $140.75
| Facility | | $140.75 | $140.75 | $140.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.75 / $140.75 / $154.82
| Professional | | $140.75 | $140.75 | $154.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.09 / $177.29 / $238.52
| Facility | | $146.09 | $177.29 | $238.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.47 / $144.47 / $144.47
| Professional | | $144.47 | $144.47 | $144.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.82 / $161.82 / $161.82
| Facility | | $161.82 | $161.82 | $161.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.82 / $161.82 / $179.16
| Professional | | $161.82 | $161.82 | $179.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.47 / $163.26 / $173.08
| Professional | | $144.47 | $163.26 | $173.08 |